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Eur Heart J Case Rep
Eur Heart J Case Rep
ehjcr
European Heart Journal. Case Reports
2514-2119
Oxford University Press UK

10.1093/ehjcr/ytae385
ytae385
Letter to the Editor
AcademicSubjects/MED00200
Insights and observations on post-septal myectomy coronary cameral fistula
https://orcid.org/0000-0001-9710-7610
Ashraf Muddasir Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Aurora Health Care, 2801 W. Kinnickinnic River Parkway, Ste. 130, Milwaukee, WI 53215, USA

https://orcid.org/0000-0001-5072-710X
Jan M Fuad Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Aurora Health Care, 2801 W. Kinnickinnic River Parkway, Ste. 130, Milwaukee, WI 53215, USA

https://orcid.org/0000-0002-4784-1275
Tajik A Jamil Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Aurora Health Care, 2801 W. Kinnickinnic River Parkway, Ste. 130, Milwaukee, WI 53215, USA

Duncker David Handling Editor
Corresponding author. Tel: +1 (414) 649-3909, Email: wi.publishing14@aah.org
9 2024
31 7 2024
31 7 2024
8 9 ytae38520 9 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.
2024
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pmcWe read with great interest the article written by Bowles et al.1 describing a unique case of coronary cameral fistula (CCF) after surgical myectomy in a patient with hypertrophic cardiomyopathy and, additionally, the importance of multimodal imaging in diagnosing CCF. Post-septal myectomy CCF was first described by Buchwald et al.2 in 1988. Bowles et al.1 have described some important clinical characteristics of CCFs. However, it is essential to mention some unique educational features of post-septal myectomy CCFs, which we recently highlighted in our article.3

We showed that patients with a post-septal myectomy CCF had deeper myectomy than patients who did not develop a post-septal myectomy CCF (septal reduction of 45% vs. 28%, P < 0.001). Furthermore, patients with a CCF were younger and had thicker septa at the time of myectomy compared with patients who did not develop a CCF. All 15 patients in our study who developed a CCF were asymptomatic and did not require any intervention, including 1 patient with follow-up available for 9 years. To date, five patients have shown spontaneous resolution of the CCF.

Large symptomatic post-septal myectomy CCFs have only been described in patients who had prior alcohol septal ablation owing to scarring of the septum; these patients may require percutaneous closure of the fistula.4 It is also important to mention that post-septal myectomy fistulas usually drain into the left ventricle as opposed to congenital CCFs, which drain into the right ventricle. Finally, it is essential to highlight that diastolic vs. systolic flow differentiates it from ventricular septal defect on Doppler echocardiography.

Key learning points

Deeper myectomy is associated with increased risk of CCF.

Younger age and thicker septum before myectomy are associated with increased risk of CCF. Most patients with post-myectomy CCF are asymptomatic and do not need intervention, including patients who have a persistent fistula for many years.

Most patients (78%) show spontaneous resolution of the fistula.

CCFs are sometimes misdiagnosed as ventricular septal defects. On Doppler, the predominant diastolic flow in the CCF, as opposed to systolic flow in a ventricular septal defect, helps in the diagnosis.

Funding: None declared.

Data availability

Data sharing is not applicable to this article as no data sets were generated or analysed.
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References

1 Bowles J , MartinJ, RussellPL, BaileyA, HollandDJ. Coronary artery fistula following surgical myectomy for hypertrophic obstructive cardiomyopathy: a case report. Eur Heart J Case Rep 2024;8 :ytae248.
2 Buchwald A , WiegandV, KreuzerH. [Coronary fistula of the right ventricular outflow tract as a complication of combined transaortic-trans-right ventricular myectomy in hypertrophic obstructive cardiomyopathy]. Z Kardiol 1988;77 :61–63.
3 Ashraf M , JaglanA, JanMF, JahangirA, SandersH, SchweitzerM, et al Post-septal myectomy coronary-cameral fistula: a brief review and search for underlying mechanisms. J Am Soc Echocardiogr 2023;36 :1008–1009.37367705
4 Sgalambro A , OlivottoI, RossiA, NistriS, BaldiniK, BaldiM, et al Prevalence and clinical significance of acquired left coronary artery fistulas after surgical myectomy in patients with hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2010;140 :1046–1052.20471659
